Remote monitoring of cardiovascular implantable devices in the pediatric population improves detection of adverse events.

With the exponential growth of cardiovascular implantable electronic devices (CIEDs) in pediatric patients, a new method of long-term surveillance, remote monitoring (RM), has become the standard of care. The purpose of this study was to determine the usefulness of RM as a monitoring tool in the pediatric population. A retrospective review was performed of 198 patients at the University of Iowa Children's Hospital who had CIEDs. Data transmitted by RM were analyzed. The following data were examined: patient demographics; median interval between transmissions; detection of adverse events requiring corrective measures, including detection of lead failure; detection of arrhythmias and device malfunctions independent of symptoms; time gained in the detection of events using RM versus standard practice; the validity of RM; and the impact of RM on data management. Of 198 patients, 162 submitted 615 RM transmissions. The median time between remote transmissions was 91 days. Of 615 total transmissions, 16 % had true adverse events with 11 % prompting clinical intervention. Of those events requiring clinical response, 61 % of patients reported symptoms. The median interval between last follow-up and occurrence of events detected by RM was 46 days, representing a gain of 134 days for patients followed-up at 6-month intervals and 44 days for patients followed-up at 3 month-intervals. The sensitivity and specificity of RM were found to be 99 and 72 %, respectively. The positive and negative predictive values were found to be 41 and 99 %, respectively. RM allows for early identification of arrhythmias and device malfunctions, thus prompting earlier corrective measures and improving care and safety in pediatric patients.

The Influence of Social Exclusion on Posttraumatic Stress Reactions in Older Adult Veterans.

The relationship between social exclusion and posttraumatic stress reactions in aging veterans is a particularly timely issue, warranting greater attention in the social work literature. Research with military veterans indicates that the social marginalization resulting from racial and ethnic discrimination can exacerbate posttraumatic stress symptoms. This marginalization suggests an increased potential for emergent or recurrent trauma reactions in aging military veterans, as previous research has documented older adults' unique risk for social exclusion. The issue takes on greater relevance as increased numbers of Vietnam veterans enter older adulthood. Professionals working with military veterans should be aware of the social and cultural factors that play a critical role in posttrauma response and recovery.

Does perceived ostracism contribute to mental health concerns among veterans who have been deployed?

Posttraumatic stress-negative psychological experiences as a result of traumatic stressors-can hinder military veterans' reintegration into society and cause various mental health problems. Veterans need quality social relationships to facilitate reintegration and to cope with posttraumatic stress and related mental health problems; discrimination or other forms of interpersonal rejection can exacerbate these veterans' problems. Ostracism (i.e., being ignored and excluded) is a painful and psychologically distressing experience that may be one factor that contributes to the problems of veterans who are dealing with posttraumatic stress. To our knowledge, this connection has yet to be tested empirically. Thus, we investigated the correlation between posttraumatic stress, perceived ostracism, and other theoretically relevant variables (i.e., mental health problems, perceived social support, psychological need satisfaction) in a sample of veterans who have had at least one deployment. Our results provide preliminary empirical evidence suggesting that perceived ostracism may contribute to veteran' deployment-related psychological problems. Veterans' perceived ostracism correlated with psychological problems (i.e., posttraumatic stress symptoms, anxiety and psychological distress), and it explained additional variance in posttraumatic stress symptoms above and beyond common predictors of these symptoms (i.e., deployment stress, perceived military and civilian-based social support). Finally, perceived ostracism emerged as the most important predictor of posttraumatic stress symptoms in a relative weights analysis.

Atrial Antitachycardia Pacing in Complex Congenital Heart Disease: A Case Series.

Among the congenital heart disease (CHD) population, intra-atrial reentrant tachycardia (IART) is a common sequela resulting from anatomical anomalies and surgical scars that significantly increases morbidity and mortality. Atrial antitachycardia pacing (ATP) delivered by atrial antitachycardia devices (ATDs) has been used to treat IART in the CHD population. However, there remains limited data on the safety and efficacy of ATP, as well as on comparisons of its effects amongst different CHD subtypes. The purpose of the current study is to describe the clinical history and ATP efficacy in three patients with unique forms of complex CHD. During this study, a single-center review of three patients with ATDs was performed. One patient with each of the following CHD anomalies was selected for inclusion: systemic left ventricle, systemic right ventricle, and single ventricle. Data collected included ATP success rates, medications in use, direct current (DC) cardioversions, and any complications related to the ATDs. Study findings revealed the patient with a systemic left ventricle had an ATD implanted for approximately 9.5 years, with 695 of 956 (73%) episodes successfully converted. Unsuccessfully treated episodes were generally asymptomatic and self-terminating in this patient. The patient with a systemic right ventricle had an ATD implanted for approximately 16 years, with 333 of 348 (96%) episodes being successfully converted. The patient with a single ventricle had an ATD implanted for approximately 12.5 years, with 404 of 416 (97%) episodes successfully converted. The patients with biventricular physiology were able to forgo DC cardioversion after receiving their ATDs. However, due to medical noncompliance as well as multiple episodes of IART, which presented with 1:1 conduction or low rates, the single-ventricle patient still required DC cardioversions post-ATD implantation. In conclusion, this study's findings demonstrate that, while ATP can be effective in a wide variety of CHDs, experiences can vary based on individual arrhythmia substrates, cardiac anatomy, and medical compliance. Additionally, challenges remain in IART detection in patients with especially complex CHD anatomies.

Safety and efficacy of atrial antitachycardia pacing in congenital heart disease.

BACKGROUND: Intra-atrial reentrant tachycardia (IART) is a common sequela in the congenital heart disease (CHD) population, and it significantly increases morbidity and mortality. Atrial antitachycardia devices (ATDs) capable of atrial antitachycardia pacing (ATP) therapy have been used to manage IART in the CHD population, but there are limited data on their safety and efficacy. OBJECTIVES: To determine whether ATD implantation was associated with reduced direct current (DC) cardioversions and to compare ATP success between different CHD diagnoses and ATP programs. METHODS: A single-center retrospective chart review was performed on CHD patients with ATDs. Demographic data were collected in addition to the number of DC cardioversions required before and after ATD implantation; data on ATP efficacy and the specific ATP program utilized; and adverse events related to ATD implantation or subsequent ATP treatments. RESULTS: ATD implantation in 91 CHD patients was associated with a significant reduction in DC cardioversions (P < .01). Overall, 72% of IART episodes were successfully terminated by ATP. Patients with levo-transposition of the great arteries experienced lower rates of ATP success than the remainder of the cohort (P < .01). There was no evidence of degeneration to ventricular arrhythmia or death directly attributed to ATP. CONCLUSION: ATD implantation was associated with reduced DC cardioversion burden. Patients with levo-transposition of the great arteries may experience lower ATP efficacy than patients with other CHDs; however, a larger patient population is required to better determine subgroup efficacy. These results support the safety and efficacy of ATP in the CHD population.

The accountability factor.

Why the continuing parade of frauds? Fraud control begins and ends with the governing board. An effective governing board controls the executive staff (not vice-versa) and actively oversees money and where and how it is spent. If accountability is the issue, the logical question is "What are the signs that accountability is not a part of the hospital or system's culture?".

Defending the next round of non-profit hospital class action lawsuits.

Recent controversies surrounding how not-for-profit hospitals price to and collect from the uninsured have resulted in class action lawsuits, investigations by state attorneys general, and other governmental investigations. The author argues that oversight at the hospital governing board level has been lax and sets forth a series of specific steps that hospital boards should take to deal with these controversies whether or not their specific hospital or hospital system has been investigated or sued.